COVID-19 Questionnaire

In light of the lockdown measures being eased for places of worship, IMI EC is currently seeking advice from the Council on the viability of holding aMuhurram program for which we must complete a Risk Assessment. For this reason we require all IMI members to complete this questionnaire to help us determine if we can comply with the health protocols and devise any mitigating safeguards.

Personal information regarding your age, occupation and contact details will be necessary. Also, please tick Yes or No if you suffer from any of the following medical conditions listed below.

– Male, aged 60 years or over
– Recipient of Organ transplants
– Having chemotherapy or immune therapy
– Having cancer treatment
– Severe lung disease for example cystic fibrosis, severe asthma, severe COPD
– Certain blood-borne disease
– Taking regular steroids or immunosuppressive
– Severe heart conditions
–  Pregnant
–  Sickle-cell disease, leukaemia, lymphoma, myeloma
– Diabetes mellitus
– Chronic kidney disease
– Liver disease for example hepatitis
– Parkinson’s disease, motor-neuron disease, multiple sclerosis or cerebral palsy
-Obesity, BMI above 35 or 40

Disclaimer: I consent to IMI collecting and holding my personal and medical data on their systems for the declared purpose. IMI will not use this data for any other purpose and will destroy this data once the stated purpose has been achieved.